Caring for Diverse Populations
Better Communication, Better Care:
A Toolkit for Physicians and
Health Care Professionals
Table of Contents
Introduction for Healthcare Professionals: Why Was This Toolkit Created?
How Can It Help My Practice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Improving Communications with a Diverse Patient Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Tips for Successful Encounters with Diverse Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Tips for Office Staff to Enhance Communication with Diverse Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Nonverbal Communication and Patient Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
“D-I-V-E-R-S-E” – A Mnemonic for Patient Encounters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Tips to Identify and Address Health Literacy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Planning Effective Written Patient Communications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Tools and Training for Your Office in Caring for a Diverse Patient Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Interview Guide for Hiring Office/Clinic Staff with Diversity Awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Online Medical Consumer Training Resources for Health Educators to Share with Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Resources to Communicate Across Language Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Tips for Communicating Across Language Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
10 Tips for Working with Interpreters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Tips for Locating Interpreter Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
U.S. Census Language Identification Flashcards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Common Signs in Multiple Languages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Common Sentences in Multiple Languages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Employee Language Skills Self-Assessment Tool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Employee Language Skills Self-Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Employee Language Skills Self-Assessment Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Primer on How Cultural Background Impacts Health Care Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Cultural Background—Information on Special Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Regulations and Standards for Cultural and Linguistic Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Standards to Provide Culturally and Linguistically Appropriate Services (CLAS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Title VI of the Civil Rights Act of 1964. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Executive Order 13166, August 2000, Improving Access
to Services for Persons With Limited English Proficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Resources for Cultural and Linguistic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Cultural Competence Website Links to Other Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Our Health Plan’s Cultural and Linguistic Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Sources Used in the Production of This Toolkit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Bibliography of Major Hard-Copy Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Bibliography of Major Internet Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Introduction for Healthcare Professionals:
Why Was This Toolkit Created?
How Can It Help My Practice?
This set of materials was produced by a team of healthcare professionals from across the country who, like you, are dedicated
to providing quality, effective, and compassionate care to their patients. Changes in U.S. demography, in our awareness of
differences in individual belief and behavior, and new legal mandates continuously present new challenges to deliver access
to health care to a diverse patient population. This toolkit was developed to provide you with resources to help address the
very specific operational needs that often arise in a busy practice because of the changing service requirements and legal
mandates.
The toolkit contents are organized into several sections, each containing helpful background information and tools that can be
reproduced and used as needed. Here are a list of the section topics and a small sample of their contents.
Resources to Assist with a Diverse Patient Population Base: Tips for providers and their clinical staff, a mnemonic to assist
with diverse patient interviews, help in identifying literacy problems, and an interview guide for hiring clinical staff with an
awareness of cultural competency issues.
Resources to Communicate Across Language Barriers: Tips for locating and working with interpreters, common signs and
common sentences in many languages, language identification flashcards, and language skill self-assessment tools.
Resources to Increase Awareness of Cultural Background and Its Impact on Health Care Delivery: Tips for talking with a
wide range of peoples across cultures about a variety of culturally sensitive topics, and information about health care beliefs
of various cultural backgrounds.
Regulations and Standards for Cultural and Linguistic Services: Some key legislation and a summary of federal “Culturally
and Linguistically Appropriate Service (CLAS) Standards,” which serve as a guide on how to meet these requirements.
Resources for Cultural and Linguistic Services: A bibliography of print and Internet resources for conducting an assessment
of the cultural and linguistic needs of your own practice’s patient population, staff and physician cultural and linguistic
competency training resources - plus links to additional tools in multiple languages and/or written for limited English proficiency.
This toolkit contains materials developed by and used with the permission of the Industry Collaboration Effort (ICE) Cultural
and Linguistics Workgroup, a “volunteer, multi-disciplinary team of providers, health plans, associations, state and federal
agencies and accrediting bodies working collaboratively to improve health care regulatory compliance through education of
the public.” More information on the ICE Workgroup may be obtained at its website: www.iceforhealth.org.
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Improving Communications with a
Diverse Patient Base
Tips for Successful Encounters
with Diverse Patients
To enable effective patient/provider communication and
to avoid being unintentionally insulting or patronizing, be
aware of the following:
Styles of Speech
People vary greatly in length of time between comment and
response, the speed of their speech, and their willingness
to interrupt.
• Tolerate gaps between questions and answers,
impatience can be seen as a sign of disrespect.
• Listen to the volume and speed of the patient’s speech
as well as the content. Modify your own speech to
more closely match that of the patient to make them
more comfortable.
• Rapid exchanges, and even interruptions, are a part of
some conversational styles. Don’t be offended when a
patient interrupts you if no offense is intended.
• Stay aware of your own pattern of interruptions,
especially if the patient is older than you are.
Eye Contact
The way people interpret various types of eye contact can
be tied to cultural background and life experience.
• Most non-Hispanic Whites expect to look people directly
in the eyes and interpret failure to do so as a sign of
dishonesty or disrespect.
• For many other cultures, direct gazing is considered
rude or disrespectful. Never force a patient to make eye
contact with you.
• If patients seem uncomfortable with direct gazes, try sitting next to them instead of across from them.
Body Language
Sociologists say that 70% to 90% of communication is
nonverbal. The meaning of body language varies greatly by
culture, class, gender, and age.
• Follow the patient’s lead on physical distance and
touching. If the patient moves closer to you or touches
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Improving Communications with a Diverse Patient Base
you, you may do the same. However, stay sensitive to
those who do not feel comfortable, and ask permission
to touch them.
• Gestures can mean very different things to different
people. Be very conservative in your own use of gestures
and body language. Ask patients about unknown gestures
or reactions.
• Do not interpret a patient’s feelings or level of pain
just from facial expressions. The way that pain or fear is
expressed is closely tied to a person’s cultural and
personal background.
Gently Guide Patient Conversation
English predisposes us to a direct communication style;
however, other languages and cultures differ.
• Initial greetings can set the tone for the visit. Many older
people from traditional societies expect to be addressed
more formally, no matter how long they have known their
physician. If the patient’s preference is not clear, ask how
he or she would like to be addressed.
• Patients from other language or cultural backgrounds
may be less likely to ask questions and more likely to
answer questions through narrative than with direct responses. Facilitate patient-centered communication
by asking open-ended questions whenever possible.
• Avoid questions that can be answered with “yes” or “no.”
Research indicates that when patients, regardless of
cultural background, are asked, “Do you understand?”
many will answer “yes,” even when they really do not
understand. This tends to be more common in teens and
older patients.
• Steer the patient back to the topic by asking a question
that clearly demonstrates that you are listening. Some
patients can tell you more about their health through
storytelling than by answering direct questions.
Tips for Office Staff to Enhance
Communication with Diverse Patients
Build rapport with the patient.
• Address patients by their last names. If the patient’s
preference is not clear, ask, “How would you like to
be addressed?”
• Focus your attention on patients when addressing them.
Determine if the patient needs an interpreter
for the visit.
• Document the patient’s preferred language in the
patient chart.
• Learn basic words in your patient’s primary language, like
“hello” or “thank you.”
• Have an interpreter access plan. An interpreter with a
medical background is preferred, rather than family or
friends of the patient.
• Recognize that patients from diverse backgrounds may
have different communication needs.
• Assess your bilingual staff for interpreter abilities. (See
Employee Language Skills Self-Assessment Tools.)
• Explain to the patient the different roles performed by
people who work in the office.
• Possible resources for interpreter services are available from
health plans, the state health department, and the Internet.
(Some resources are listed at the end of this toolkit.)
Make sure patients know what you do.
• Take a few moments to prepare a handout that explains
office hours, how to contact the office when it is closed,
and how the doctor arranges for care (when the doctor is
the first point of contact and then refers to specialists).
• Have instructions translated by a professional translator
and available in the common language(s) spoken by your
patient base.
Recognize that patients from diverse backgrounds
may have different communication needs.
Keep patients’ expectations realistic.
• Inform patients of delays or extended waiting times. If
the wait is longer than 15 minutes, encourage the patient
to make a list of questions for the doctor, review health
materials or view waiting room videos.
Give patients the information they need.
• Have topic-specific health education materials in
languages that reflect your patient base.
• Offer handouts such as immunization guidelines for
adults and children, screening guidelines, and culturally
relevant dietary guidelines for diabetes or weight loss.
Make sure patients know what to do.
• Review any follow-up procedures with the patient and
family before they leave your office.
• Verify call back numbers, the locations for follow-up
services such as labs, X-ray or screening tests, and
whether or not a follow-up appointment is necessary.
• Develop pre-printed simple handouts of frequently used
instructions, and translate the handouts into the
common language(s) spoken by your patient base.
NOTE: See commonly used sentences and signs provided in
this toolkit.
Work to build patients’ trust in you.
• Inform patients of office procedures, such as when
they can expect a call with lab results, how follow-up
appointments are scheduled, and routine wait times.
Improving Communications with a Diverse Patient Base
5
Nonverbal Communication
and Patient Care
Nonverbal communication is a subtle form of communication that is initiated in the first three seconds upon meeting
someone for the first time and continues through the entire
interaction. Research indicates that nonverbal communication
accounts for approximately 70% to 90% of a communication episode. Nonverbal communication can impact the
success of communication more acutely than the spoken
word. Our culturally informed unconscious framework evaluates gestures, appearance, body language, the face, and
and never met her eyes. She reasoned from this that he
was uninterested and therefore not listening to her.1
how space is used. Yet, we are rarely aware of how persons
from other cultures may perceive our nonverbal communication or the subtle cues we have used to assess the person.
Touch and Use of Space
The following are case studies that provide examples of
nonverbal miscommunication that may sabotage a
patient-provider encounter. Broad cultural generalizations
are used for illustrative purposes. They should not be
mistaken for stereotypes. A stereotype and a generalization
may appear similar, but they function very differently:
• A stereotype is an ending point; no attempt is made
to learn whether the individual in question fits
the statement.
• A generalization is a beginning point; it indicates
common trends, but further information is needed to
ascertain whether the statement is appropriate to a
particular individual.
Generalizations can serve as a guide to be accompanied
by individualized in-person assessment. As a rule, ask the
patient, rather than assume you know the patient’s needs
and wants. If asked, patients will usually share their personal
beliefs, practices and preferences related to prevention,
diagnosis and treatment.
Eye Contact
Ellen was trying to teach her Navajo patient, Jim Nez,
how to live with his newly diagnosed diabetes. She soon
became extremely frustrated because she felt she was
not getting through to him. He asked very few questions
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Improving Communications with a Diverse Patient Base
It is rude to meet and hold eye contact with an elder or
someone in a position of authority such as health professionals in most Latino, Asian, American Indian and many
Arab countries. It may be also considered a form of social
aggression if a male insists on meeting and holding eye
contact with a female.
A physician with a large medical group requested
assistance encouraging young female patients to make
and keep their first well-woman appointment. The
physician stated that this group had a high no-show rate
and appointments did not go as smoothly as the
physician would like.
Talk the patient through each exam so that the need for the
physical contact is understood, prior to the initiation of the
examination. Ease into the patients’ personal space. If there
are any concerns, ask before entering the three-foot zone.
This will help ease the patient’s level of discomfort and
avoid any misinterpretation of physical contact. Additionally,
physical contact between a male and female is strictly
regulated in many cultures. An older female companion
may be necessary during the visit.
Gestures
A non-Hispanic White patient named James Todd called
out to Elena, a Filipino nurse: “Nurse, nurse.” Elena came
to Mr. Todd’s door and politely asked, “May I help you?”
Mr. Todd beckoned her to come closer by motioning with
his right index finger. Elena remained where she was and
responded in an angry voice, “What do you want?”
Mr. Todd was confused. Why had Elena’s manner
suddenly changed? 2
Gestures may have dramatically different meanings across
cultures. It is best to think of gestures as a local dialect that
is familiar only to insiders of the culture. Conservative
use of hand or body gestures is recommended to avoid
misunderstanding. In the case above, Elena took offense
to Mr. Todd’s innocent hand gesture. In the Philippines
(and in Korea) the “come here” hand gesture is used to
call animals.
Body Posture and Presentation
Carrie was surprised to see that Mr. Ramirez was dressed
very elegantly for his doctor’s visit. She was confused by
his appearance because she knew that he was receiving
services on a sliding fee scale. She thought the front
office either made a mistake documenting his ability to
pay for service, or that he falsely presented his income.
Many cultures prioritize respect for the family and
demonstrate family respect in their manner of dress
and presentation in public. Regardless of the economic
resources that are available or the physical condition of
the individual, going out in public involves creating an
image that reflects positively on the family—the clothes
are pressed, the hair is combed, and shoes are clean. A
person’s physical presentation is not an indicator of their
economic situation.
Use of Voice
Dr. Moore had three patients waiting and was feeling
rushed. He began asking health-related questions of his
Vietnamese patient, Tanya. She looked tense, staring at
the ground without volunteering much information. No
matter how clearly he asked the question, he couldn’t get
Tanya to take an active part in the visit.
The use of voice is perhaps one of the most difficult forms
of nonverbal communication to change, as we rarely hear
how we sound to others. If you speak too fast, you may be
seen as not being interested in the patient. If you speak
too loud, or too soft for the space involved, you may be
perceived as domineering or lacking confidence. Expectations for the use of voice vary greatly between and within
cultures, for male and female, and the young and old.
The best suggestion is to search for nonverbal cues to
determine how your voice is affecting your patient.
1, 2 Galanti, G. (1997). Caring for Patients from Different Cultures. University
of Pennsylvania Press.
Hall, E.T. (1985). Hidden Differences: Studies in International Communication.
Hamburg: Gruner & Jahr.
Hall, E.T. (1990). Understanding Cultural Differences. Yarmouth, ME:
Intercultural Press.
Improving Communications with a Diverse Patient Base
7
“D-I-V-E-R-S-E” – A Mnemonic for Patient Encounters
A mnemonic will assist you in developing a personalized care plan based on cultural/diversity aspects. Place in the patient’s
chart or use the mnemonic when gathering the patient’s history.
Assessment
D
I
8
Demographics - Explore regional
background, level of acculturation,
age and sex as they influence
health care behaviors.
Sample Questions
• Where were you born?
• Where was “home” before coming to the U.S.?
• How long have you lived in the U.S.?
• What is the patient’s age and sex?
Ideas - Ask the patient to explain
• What do you think keeps you healthy?
his/her ideas or concepts of health • What do you think makes you sick?
and illness.
• What do you think is the cause of your illness?
• Why do you think the problem started?
V
Views of health care treatments Ask about treatment preference,
use of home remedies, and
treatment avoidance practices.
E
Expectations - Ask about what your • What do you hope to achieve from today’s visit?
patient expects from his/her doctor? • What do you hope to achieve from treatment?
• Do you find it easier to talk with a male/female?
Someone younger/older?
R
Religion - Ask about your patient’s
religious and spiritual traditions.
• Will religious or spiritual observances affect
your ability to follow treatment? How?
• Do you avoid any particular foods?
• During the year, do you change your diet in
celebration of religious and other holidays?
S
Speech - Identify your patient’s
language needs, including health
literacy levels. Avoid using a family
member as an interpreter.
• What language do you prefer to speak?
• Do you need an interpreter?
• What language do you prefer to read?
• Are you satisfied with how well you read?
• Would you prefer printed or spoken instructions?
E
Environment - Identify patient’s home
environment and the cultural/
diversity aspects that are part of
the environment. Home environment
includes the patient’s daily schedule,
support system and level of
independence.
• Do you live alone?
• How many other people live in your house?
• Do you have transportation?
• Who gives you emotional support?
• Who helps you when you are ill or need help?
• Do you have the ability to shop/cook for yourself?
• What times of day do you usually eat?
• What is your largest meal of the day?
• Are there any health care procedures that might
not be acceptable?
• Do you use any traditional or home health
remedies to improve your health?
• What have you used before?
• Have you used alternative healers? Which?
• What kind of treatment do you think will work?
Improving Communications with a Diverse Patient Base
Assessment Information/
Recommendations
Improving Communications with a Diverse Patient Base
9
Tips to Identify and Address Health Literacy Issues
Low health literacy can prevent patients from
understanding their health care services.
Health Literacy is defined by the National Health Education
Standards as “the capacity of an individual to obtain, interpret, and understand basic health information and services
and the competence to use such information
and services in ways which are health-enhancing.” This
includes the ability to understand written instructions on
prescription drug bottles, appointment slips, medical
education brochures, doctors' directions, consent forms
and the ability to negotiate complex health care systems.
Health literacy is not the same as the ability to read and is
not necessarily related to years of education. A person who
functions adequately at home or work may have marginal
or inadequate literacy in a health care environment.
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Improving Communications with a Diverse Patient Base
Barriers to Health Literacy
• The ability to read and comprehend health information
is impacted by a range of factors including age, socioeconomic background, education and culture. Example:
Some seniors may not have had the same educational
opportunities afforded to them.
• A patient’s culture and life experience may have an
effect on their health literacy. Example: A patient’s
background culture may stress verbal, not written,
communication styles.
• An accent, or a lack of an accent, can be misread as an
indicator of a person’s ability to read English. Example:
A patient, who has learned to speak English with very
little accent, may not be able to read instructions on a
prescription bottle.
Health literacy is not the same as the ability to
read and is not necessarily related to years of
education. A person who functions adequately at
home or work may have marginal or inadequate
literacy in a health care environment.
• Ask patients to repeat back to you important
information.
• Ask open-ended questions.
• Use medically trained interpreters familiar with
cultural nuances.
• Give information in small chunks.
• Articulate words.
• Different family dynamics can play a role in how a patient
receives and processes information.
• “Read” written instructions out loud.
• In some cultures it is inappropriate for people to discuss
certain body parts or functions leaving some with a very
poor vocabulary for discussing health issues.
• Use body language to support what you are saying.
• In adults, reading skills in a second language may take
6–12 years to develop.
• Use video and audio media as an alternative
to written communications.
• Speak slowly (don’t shout).
• Draw pictures; use posters, models or
physical demonstrations.
Possible Signs of Low Health Literacy
Your patients may frequently say:
• I forgot my glasses.
• My eyes are tired.
• I’ll take this home for my family to read.
• What does this say? I don’t understand this.
Your patients’ behavior may include:
• Not getting their prescriptions filled, or not taking
their medications as prescribed.
• Consistently arriving late to appointments.
• Returning forms without completing them.
• Requiring several calls between appointments to
clarify instructions.
Tips for Dealing with Low Health Literacy
• Use simple words and avoid jargon.
• Never use acronyms.
• Avoid technical language (if possible).
• Repeat important information—a patient’s logic
may be different from yours.
Improving Communications with a Diverse Patient Base
11
Planning Effective Written Patient
Communications
All medical offices have written communication campaigns
to their diverse patient base, whether it is to announce
business operation changes, or health improvement reminders about routine vaccinations or the importance of
preventive health screenings.
Here are some tips to help increase the effectiveness of
your office’s written communication campaign. When developing your message, think through what you expect the
outcome to be. Ask:
• Who is your target audience?
• What is the objective of the communication?
• What does a patient need to know to get the result you
want?
• What is the call to action or the desired behavior?
• How will you best clarify the benefit of taking this action?
If yours is a more targeted mailing campaign, think about
gender, age, stage of life (single, family, empty nesters),
geography, the type of insurance coverage, and even race/
ethnicity where appropriate.
Our health plan conducted extensive research with racial
and ethnic minority group patients and found that the most
effective communication materials that engaged patients
and induced action shared several key elements. These
themes are integral components of culturally relevant
communication initiatives.
We call these themes the “5 F’s”: Food, Family, Faith, Fear,
and Finances.
• Food. Affinity to cultural foods and difficulties in changing
dietary habits
• Family. Particularly “being there” for children and
grandchildren
• Faith and Spirituality. Respecting life as a gift; recognizing
faith-based entities as trusted sources of health information
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Improving Communications with a Diverse Patient Base
• Fear. Disease complications, especially amputations,
blindness, and kidney disease, or myths regarding adverse
outcomes from treatments
• Finances. Affordability of health care and healthy lifestyles
(e.g., food, gym membership, testing strips, and copays)
While all these themes may not always be relevant to a
specific communication topic, framing the benefits to the
patient -- from defining a call to action to weaving in culturally
appropriate and sensitive discussions of the relevant 5 F
themes -- may help your message resonate more effectively
with your diverse patient base.
Tools and Training for Your Office in Caring
for a Diverse Patient Base
Interview Guide for Hiring Office/Clinic
Staff with Diversity Awareness
The following set of questions is meant to help you determine whether a
job candidate will be sensitive to the cultural and linguistic needs of your
patient population. By integrating some or all of these questions into your
interview process, you will be more likely to hire staff that will help you create
an office/clinic atmosphere of openness, affirmation, and trust between
patients and staff. Remember that bias and discrimination can be obvious and
flagrant or small and subtle. Hiring practices should reflect this understanding.
Sample Interview Questions
Q: What experience do you have in working with people
of diverse backgrounds, cultures and ethnicities? The
experiences can be in or out of a health care environment.
The interviewee should demonstrate understanding and
willingness to serve diverse communities. Any experience,
whether professional or volunteer, is valuable.
Q: Please share any particular
challenges or successes you
have experienced in working with
people from diverse backgrounds.
You will want to get a sense that the
interviewee has an appreciation for
working with people from diverse
backgrounds and understands the
accompanying complexities and
needs in an office setting.
Q: In the health care field we come across patients of
different ages, language preferences, sexual orientations,
religions, cultures, genders, and immigration status,
etc. all with different needs. What skills from your past
customer service or community/healthcare work do you
think are relevant to this job?
This question should allow a better understanding of the
interviewee's approach to customer service across the
spectrum of diversity, his or her previous experience, and if
his or her skills are transferable to the position in question.
Look for examples that demonstrate an understanding of
varying needs. Answers should demonstrate listening and
clear communication skills.
Q: What would you do to make all patients feel respected?
For example, some Medicaid or Medicare recipients may
be concerned about receiving substandard care because
they lack private insurance.
The answer should demonstrate an understanding of the
behaviors that facilitate respect and the type of prejudices
and bias that can result in substandard service and care.
14
Tools and Training for Your Office in Caring for a Diverse Patient Base
Online Medical Consumer Training Resources for
Health Educators to Share with Patients
Racial and ethnic minority communities as a whole have
had greater difficulty with the American health care system
than white Americans. One in three Hispanics and one in four
African Americans and Asian Americans report experiencing
difficulties communicating with health care providers as
opposed to one in six white Americans (The Commonwealth
Fund, 2002).
More recently, the 2010 National Healthcare Disparities
Report (NHDR), which tracked patient-provider communication, found that between 2002 and 2007, the percentage
of White, middle-income, and high-income adults who
reported poor communication with their health providers
significantly decreased.
Such reticence often leads to a common scenario in which
a doctor would say, “but the patient seemed like he understood my instructions; why didn’t he follow my treatment
plan?”
Research has shown that successful programs to close the
gap in chronic disease-related health disparities in various
racial and ethnic populations are built on strengthening the
links between health care providers and their patients (Roe
& Thomas, 2002).
However, racial and ethnic disparities in patient reports
of provider communication have persisted over the past
decade.
• In all years, Hispanics were significantly more likely than
non-Hispanic Whites to report poor communication.
• In 4 of 6 years, Black patients were more likely than
Whites to report poor communication with health providers; the exceptions were 2006 and 2007.
• In 5 of 6 years, Asians were more likely than Whites to
report poor communication; the exception was 2007.
Patients may not have the communication skills needed
to share information vital to accurate diagnosis or optimal
treatment. In cases of patients with diverse ethnic backgrounds, linguistic, cultural and/or health literacy may be
barriers to being active participants of their own health care.
These same barriers may also keep patients from speaking up to:
• Ask questions to fully understand their medical conditions
or treatment instructions
• Share personal challenges in adhering to recommended
treatment
Tools and Training for Your Office in Caring for a Diverse Patient Base
15
On the one hand, while training courses abound for clinicians on effective cross-cultural communication skills,
there are scant few resources that guide patients to be
more empowered health care consumers.
We support health care professionals and health educators in encouraging patients to be more active, engaged
and empowered health care consumers. We have created a
web-based resource to help health care professionals guide
patients toward improving their medical consumerism
skills such as:
• How to prepare for health care visits
• How to communicate effectively with health care professionals
• How to navigate of the U.S. health care system
• Different types of medical providers and care settings
• U.S. concepts of health, wellness and medicine
• Patient’s rights and responsibilities
• Access to health education program offerings (public
sources as well as those from health plans such as
disease management or health coaching programs)
This course is available at no cost to all health care professionals at BridgingHealthCareGaps.com.
_________________________________________________
Agency for Healthcare Research and Quality (2010 June). The 2010 National Healthcare Disparities Report (NHDR).
The Commonwealth Fund (2002, March). Diverse communities, common
concerns: Assessing health care quality for minority Americans.
Roe, K., & Thomas, S. (2002). Acknowledgements. Health Promotion Practice, 3(October), 106-107.
16
Tools and Training for Your Office in Caring for a Diverse Patient Base
Resources to Communicate Across
Language Barriers
Tips for Communicating Across
Language Barriers
Limited English Proficient (LEP) patients are faced with
language barriers that undermine their ability to understand information given by healthcare providers as well
as instructions on prescriptions and medication bottles,
appointment slips, medical education brochures, doctors'
directions, and consent forms. They experience more
difficulty (than other patients) processing information
necessary to care for themselves and others.
Tips to Identify a Patient’s Preferred Language
• Ask the patient for his or her preferred spoken and
written language.
• Display a poster of common languages spoken by patients;
ask them to point to their language of preference.
• Post information relative to the availability of
interpreter services.
• Make available and encourage patients to carry “I speak…”
or “Language ID” cards. (Note: Many phone interpreter companies provide language posters and cards at no charge.)
Tips to Document Patient Language Needs
• For all Limited English Proficient (LEP) patients,
document preferred language in paper and/or
electronic medical records.
• Post color stickers on the patient’s chart to flag
when an interpreter is needed. (e.g., Orange=Spanish,
Yellow=Vietnamese, Green=Russian).
Tips to Assess Which Type of Interpreter to Use
• Telephone interpreter services are easily accessed and available for short conversations or unusual language requests.
• Face-to-face interpreters provide the best communication
for sensitive, legal or long communications.
• Trained bilingual staff provides consistent patient
interactions for a large number of patients.
• For reliable patient communication, avoid using minors
and family members.
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Resources to Communicate Across Language Barriers
Tips to Overcome Language Barriers
• Use simple words; avoid jargon and acronyms.
• Limit/avoid technical language.
• Speak slowly (don’t shout).
• Articulate words completely.
• Repeat important information.
• Provide educational material in the languages your
patients read.
• Use pictures, demonstrations, video or audiotapes to
increase understanding.
• Give information in small chunks and verify comprehension
before going on.
• Always confirm that the patient understands the information—
the patient’s logic may be different from yours.
10 Tips for Working with Interpreters
1. Choose an interpreter who meets the
needs of the patient, considering age, sex
and background.
A patient might be reluctant to disclose personal
and sensitive information, for example, in front of an
interpreter of a different sex.
2. Hold a brief introductory discussion with the
interpreter.
If it is your first time working with a professional interpreter, briefly meet with the interpreter first to agree
on basic interpretation protocols. Let the interpreter
brief the patient on the interpreter’s role.
3. Allow enough time for the interpreted sessions.
Remember that an interpreted conversation requires
more time. What can be said in a few words in one
language may require a lengthy paraphrase in another.
4. Speak in a normal voice, clearly, and not too
fast or too loudly.
It is usually easier for the interpreter to understand
speech produced at normal speed and with normal
rhythms, than artificially slow speech.
5. Avoid acronyms, jargon, and technical terms.
Avoid idioms, technical words, or cultural references
that might be difficult to translate. Some concepts may
be easy for the interpreter to understand but extremely
difficult to translate (e.g., positive test results).
6. Face the patient and talk to the patient
directly. Be brief, explicit and basic.
Remember that you are communicating with the patient
through an interpreter. Pause after a full thought for
the interpretation to be accurate and complete. If you
speak too long, the interpreter may not remember and
miss what was said.
7. Don’t ask or say anything that you don’t
want the patient to hear.
Expect everything you say to be interpreted, and
everything the patient and his or her family says.
8. Be patient and avoid interrupting during
interpretation.
Allow the interpreter as much time as necessary to ask
questions, for repeats, and for clarification. Be prepared
to repeat yourself in different words if your message
is not understood. Professional interpreters do not
translate word-for-word but rather concept-by-concept.
Also remember that English is a direct language, and
may need to be relayed into complex grammar and a
different communication pattern.
9. Be sensitive to appropriate communication
standards.
Different cultures have different protocols to discuss
sensitive topics and to address physicians. Many
ideas taken for granted in America do not exist in the
patient’s culture and may need detailed explanation in
another language. Take advantage of your interpreter’s
insight and let the interpreter be your “Cultural Broker.”
10.Read body language in the cultural context.
Watch the patient’s eyes, facial expression, or body
language when you speak and when the interpreter
speaks. Look for signs of comprehension, confusion,
agreement, or disagreement.
Note: When working with interpreters, reassure the patient
that the information will be kept confidential.
Resources to Communicate Across Language Barriers
19
Tips for Locating Interpreter Services
First, assess the oral linguistic needs of your Limited
English Proficient (LEP) patients. Second, assess the
services available to meet these needs.
Assess the language capability of your staff (See Employee
Language Skills Self-Assessment)
• Keep a list of available bilingual staff who can assist with
LEP patients on-site.
• Assess services available through patient health plans.
• Ask all health plans you work with if and when they provide
interpreter services, including American Sign Language
interpreters, as a covered benefit for their members.
Keep an updated list of specific telephone numbers
and health plan contacts for language services.
• Identify the policies and procedures in place to access
interpreter services for each plan you work with.
• Keep an updated list of specific telephone numbers and
health plan contacts for language services.
• Ask the agency providing the interpreter for their training
standards and methods of assessing interpreter quality.
• Don’t forget to inquire about Telecommunication Device
for the Deaf (TDD) services for the hard of hearing/deaf.
If services are covered, identify the appropriate contact
and request the health plan’s process to access services.
• Determine if face-to-face and/or telephone interpreters
are covered.
• If face-to-face interpreters are covered, have the following
information ready before requesting the interpreter:
gender, age, language needed, date/time of appointment,
type of visit, and office specialty.
20
Resources to Communicate Across Language Barriers
- Remember to follow all HIPAA regulations when
transmitting any patient-identifiable information to
parties outside your office.
• If telephone interpreters are covered, relay the pertinent
patient information which will help the interpreter better
serve the needs of the patient and the provider.
If interpreter services are NOT covered by the patient’s
health plan, find other resources to meet the linguistic
needs of your LEP patients.
• Use trained/capable internal staff.
• Consider contracting with a telephonic interpreting company.
• Check for services available through Community Based
Organizations. Some provide free face-to-face interpreter
services for the community or they may offer low fees.
• Depending on the linguistic needs of your LEP population,
you may have to consider hiring a professional interpreter.
• For further information, you may contact the National
Council on Interpretation in Health Care, the Society of
American Interpreters, the Translators & Interpreters
Guild, the American Translators Association, or any local
Health Care Interpreters association in your area.
U.S. Census Language Identification Flashcards
The sheets in this tool can be used to assist the office staff or physician in identifying the language that your patient is speaking.
Pass the sheets to the patient and point to the English statement. Motion to the patient to read the other languages and to
point to the language that the patient prefers. (Conservative gestures can communicate this.) Record the patient’s language
preference in his or her medical record.
The Language Identification Flashcards were developed by the U.S. Census Department and can be used to identify most
languages that are spoken in the United States.
Resources to Communicate Across Language Barriers
21
2004
Census
Test
2010
LANGUAGE IDENTIFICATION FLASHCARD
.á«Hô©dG çóëàJ hCG CGô≤J âæc GPEG ™HôŸG Gòg ‘ áeÓY ™°V
1. Arabic
2. Armenian
3. Bengali
QUmbJÇak'kñ¨g®b/b'enH ebI/ñk/an …niXaXPasa e‡oµe .
4. Cambodian
Motka i kahhon ya yangin ûntûngnu' manaitai pat ûntûngnu' kumentos Chamorro.
5. Chamorro
6. Simplified
Chinese
7. Traditional
Chinese
Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik.
8.Croatian
Zaškrtněte tuto kolonku, pokud čtete a hovoříte česky.
9. Czech
Kruis dit vakje aan als u Nederlands kunt lezen of spreken.
10. Dutch
Mark this box if you read or speak English.
11. English
12. Farsi
DB-3309
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
22
Resources to Communicate Across Language Barriers
Cocher ici si vous lisez ou parlez le français.
13. French
Kreuzen Sie dieses Kästchen an, wenn Sie Deutsch lesen oder sprechen.
14. German
15. Greek
16. Haitian
Creole
Make kazye sa a si ou li oswa ou pale kreyòl ayisyen.
17. Hindi
Kos lub voj no yog koj paub twm thiab hais lus Hmoob.
18. Hmong
Jelölje meg ezt a kockát, ha megérti vagy beszéli a magyar nyelvet.
19. Hungarian
Markaam daytoy nga kahon no makabasa wenno makasaoka iti Ilocano.
20. Ilocano
Marchi questa casella se legge o parla italiano.
21. Italian
22. Japanese
23. Korean
24. Laotian
Prosimy o zaznaczenie tego kwadratu, jeżeli posługuje się Pan/Pani
językiem polskim.
DB-3309
25. Polish
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
Resources to Communicate Across Language Barriers
23
26. Portuguese
Assinale este quadrado se você lê ou fala português.
27. Romanian
�ометьте этот квадратик, если вы читаете или говорите по-русски.
28. Russian
29. Serbian
Označte tento štvorček, ak viete čítať alebo hovoriť po slovensky.
30. Slovak
Marque esta casilla si lee o habla español.
31. Spanish
Markahan itong kuwadrado kung kayo ay marunong magbasa o magsalita ng Tagalog.
32. Tagalog
33. Thai
Maaka 'i he puha ni kapau 'oku ke lau pe lea fakatonga.
34. Tongan
�ідмітьте цю клітинку, якщо ви читаєте або говорите українською мовою.
35. Ukranian
36. Urdu
Xin ñaùnh daáu vaøo oâ naøy neáu quyù vò bieát ñoïc vaø noùi ñöôïc Vieät Ngöõ.
37. Vietnamese
38. Yiddish
DB-3309
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
24
Resources to Communicate Across Language Barriers
Common Signs in Multiple Languages
(English-Spanish-Vietnamese-Chinese)
You may wish to use this tool to mark special areas in your office to help your Limited English Proficient (LEP) patients. It is
suggested that you laminate each sign and post it.
English
Español
Tieáng Vieät
中文
Welcome
Spanish
Vietnamese
Chinese
English
Español
Tieáng Vieät
中文
Tieáng Vieät
中文
Spanish
Vietnamese
Chinese
中文
Spanish
Vietnamese
Chinese
Tieáng Vieät
中文
Oficina de Registro
QuaÀy tieáp khaách
登記處
Cajera
Quaày traû tieàn
收銀部
Enter
Spanish
Entrada
Vietnamese
Loái vaøo
Chinese
English
Español
歡迎
Cashier
English
Español
Haân haïnh tieáp ñoùn quyù vò
Registration
English
Español
Bienvenido/a
入口
Restroom
Spanish
Vietnamese
Chinese
Baños
Phoøng veä sinh
洗手間
Resources to Communicate Across Language Barriers
25
Common Sentences in Multiple Languages
(English-Spanish-Vietnamese-Chinese)
This tool is designed for office staff to assist in basic entry-level communication with Limited English Proficient (LEP) patients.
Point to the sentence you wish to communicate and your LEP patient may read it in his/her language of preference. The
patient can then point to the next message.
English
Chinese / 中文
Spanish / Español
☛
☛
☛
☛
☟
Point to a sentence
Señale una frase
Xin chæ vaøo caâu
指向句子
Instructions
Instrucciones
Chæ Daãn
指示
We can use these cards to
help us understand each
other. Point to the sentence
you want to communicate. If
needed, later we will call an
interpreter.
Chuùng ta coù theå duøng
nhöõng theû naøy ñeå giuùp
chuùng ta hieåu nhau. Xin chæ
vaøo caâu ñuùng nghóa quyù vò
muoán noùi. Chuùng toâi seõ nhôø
moät thoâng dòch vieân ñeán
giuùp neáu chuùng ta caàn noùi
nhieàu hôn.
Podemos utilizar estas
tarjetas para entendernos.
Señale la frase que desea
comunicar. Si necesita,
después llamaremos a un
intérprete.
這卡可以幫助大家更明白
對方。請指向您想溝通的
句子， 如有需要，稍後我
們可以為您安排傳譯員。
☟
Courtesy statements
Frases de cortesía
Töø ngöø lòch söø
禮貌敘述
Please wait.
Por favor espere
(un momento).
Xin vui loøng chôø.
請等等
Thank you.
Gracias.
Caùm ôn.
多謝
One moment, please.
Un momento, por favor.
Xin ñôïi moät chuùt.
請等一會
☛
Point to a sentence
Señale una frase
Xin chæ vaøo caâu
指向句子
Patient may say…
El paciente puede decir…
Beänh nhaân coù theå noùi…
病人可能會說…
☛
☟
☛
☛
26
☛
指向句子
☛
Xin chæ vaøo caâu
☛
Señale una frase
☛
☟
Point to a sentence
My name is…
Mi nombre es...
Toâi teân laø...
我的名字是…
I need an interpreter.
Necesito un intérprete.
Chuùng toâi caàn thoâng dòch vieân.
我需要一位傳譯員…
I came to see the doctor,
because…
Vine a ver al doctor porque… Toâi muoán gaëp baùc só vì…
I don’t understand.
No entiendo.
Toâi khoâng hieåu.
我不明白
Please hurry. It is urgent.
Por favor apúrese. Es
urgente.
Vui loøng nhanh leân. Toâi coù
chuyeän khaån caáp.
請盡快，這是非常緊急。
Where is the bathroom?
¿Dónde queda el baño?
Phoøng veä sinh ôû ñaâu?
洗手間在那裏?
How much do I owe you?
¿Cuánto le debo?
Toâi caàn phaûi traû bao nhieâu tieàn? 可否找一位傳譯員?
Is it possible to have an
interpreter?
¿ Es posible tener un
intérprete?
Coù theå nhôø moät thoâng dòch
傳譯員就快到。
vieân ñeán giuùp chuùng ta khoâng?
Resources to Communicate Across Language Barriers
我來見醫生是因為…
English
Chinese / 中文
Spanish / Español
☛
☛
☛
☛
☟
Point to a sentence
Señale una frase
Xin chæ vaøo caâu
指向句子
Staff may ask or say…
El personal del médico
le puede decir…
Nhaân vieân coù theå hoûi
hoaëc noùi…
職員可能會問或說…
How may I help you?
¿En qué puedo ayudarle?
Toâi coù theå gíup ñöôïc gì?
我怎樣可以幫您呢?
I don’t understand. Please
wait.
No entiendo. Por favor
espere.
Toâi khoâng hieåu. Xin ñôïi
moät chuùt.
我不明白，請等等。
What language do you
prefer?
¿Qué idioma prefiere?
Quí vò thích duøng ngoân ngöõ
naøo?
您喜歡用什麼語言呢 :
• Cantonese 廣東話
• Mandarin 國語
We will call an interpreter.
Vamos a llamar a un
intérprete.
Chuùng toâi seõ goïi thoâng dòch
vieân
我們會找一位傳譯員。
An interpreter is coming.
Ya viene un intérprete.
Seõ coù moät thoâng dòch vieân
ñeán giuùp chuùng ta.
傳譯員就快到。
What is your name?
¿Cuál es su nombre?
Quùy vò teân gì?
您叫什麼名字 ?
¿Quién es el paciente?
Ai laø beänh nhaân?
誰是病人 ?
Please write the patient’s:
Por favor escriba, acerca del
paciente:
Xin vieát lyù lòch cuûa beänh
nhaân:
請寫出病人的 :
Name
Nombre
Teân
姓名
Address
Dirección
Ñòa Chæ
地址
Telephone number
Número de teléfono
Soá Ñieän Thoaïi
電話號碼
Identification number
Número de identificación
Soá ID
醫療卡號碼
Birth date:
Fecha de nacimiento:
Ngaøy Sinh:
出生日期 :
Who is the patient?
Month/Day/Year
Mes/Día/Año
Thaùng/Ngaøy/Naêm
月/日/年
Now, fill out
these forms, please
Ahora, por favor
conteste estas formas.
Baây giôø xin ñieàn
nhöõng ñôn naøy.
現在，請填寫這表格
☟
Resources to Communicate Across Language Barriers
27
Employee Language Skills
Self-Assessment Tool
The attached self-assessment tool can assist you in identifying language skills and resources existing in your health care setting.
This simple tool will provide a basic and subjective idea of the bilingual capabilities of your staff. We recommend that you
distribute the tool to all your clinical and non-clinical employees using their non-English language skills in the workplace.
The information collected may be used as a first step to improve communication with your diverse patient base.
You may wish to write an introductory note along the following lines:
“We are committed to maintaining our readiness to serve the needs of our patients. Many of our employees could use their
skills in languages other than English. We are compiling information about resources available within our work force.
Please complete and return this survey to <department/contact> no later than <date>. This survey will not affect your
performance evaluation. It is just a way for us to improve our customer service, and to make you part of such efforts.
Thank you for your assistance.”
Once bilingual staff have been identified, they should be referred to professional assessment agencies to evaluate the level
of proficiency. There are many sources that will help you assess the bilingual capacity of staff. Depending on their level of
confirmed fluency, your practice would be able to make use of this added value to help your practice better communicate
with your patients in the client’s language of preference.
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Resources to Communicate Across Language Barriers
Employee Language Skills Self-Assessment
Thank you for participating in this survey process. This survey is for staff who currently use their skills in languages other than
English to communicate with our patients. Be assured that this survey will not affect your performance evaluation. This is a
way for us to identify our linguistic strengths, determine training opportunities, improve our customer service and include you
in our diversity efforts.
Employee Name:_____________________________ Department:__________________________ Work hours:q 8am–5pm
q9am-6pm
Directions:
(1) Write any/all language(s) or dialects you know.
qother_____
(2) Indicate how fluently you speak, read and/or write in that language. (see attached key)
(3) Specify if you currently use this language regularly in your job.
E X A M P L E
Language
Dialect,
region…
Speaking
Reading
Writing
do you speak…
do you read…
do you write…
Spanish
Mexico
12345
12345
12345
Yes No
Yes No
Yes No
As part of your
job, do you use
this language
to speak with
patients?
(Circle)
As part of
your job, do
you read this
language?
(Circle)
As part of
your job, do
you write this
language?
(Circle)
Language
Dialect,
region or
country
Fluency: see attached key
(Circle)
Speaking
Reading
Writing
1.
12345
12345
12345
Yes No
Yes No
Yes No
2.
12345
12345
12345
Yes No
Yes No
Yes No
3.
12345
12345
12345
Yes No
Yes No
Yes No
4.
12345
12345
12345
Yes No
Yes No
Yes No
Resources to Communicate Across Language Barriers
29
Employee Language Skills Self-Assessment Key
Key for Spoken Language Capability
Key
Spoken Language
(1)
Satisfies elementary needs and minimum courtesy requirements. Able to understand and respond to
2-3 word entry-level questions. May require slow speech and repetition.
(2)
Meets basic conversational needs. Able to understand and respond to simple questions. Can handle
casual conversation about work, school, and family. Has difficulty with vocabulary and grammar.
(3)
Able to speak the language with sufficient accuracy and vocabulary to have effective formal and informal
conversations on most familiar topics related to health care.
(4)
Able to use the language fluently and accurately on all levels related to work needs. Can understand and
participate in any conversation within the range of his/her experience with a high degree of fluency and
precision of vocabulary. Unaffected by rate of speech.
(5)
Speaks proficiently equivalent to that of an educated native speaker. Has complete fluency in the
language such that speech in all levels is fully accepted by educated native speakers in all its features,
including breadth of vocabulary and idioms, colloquialisms, and pertinent cultural preferences. Usually
has received formal education in target language.
Key for Reading Capability
Key
Reading
(1)
No functional ability to read. Able to understand and read only a few key words.
(2)
Limited to simple vocabulary and sentence structure.
(3)
Understands conventional topics, non-technical terms and health care terms.
(4)
Understands materials that contain idioms and specialized terminology; understands a broad
range of literature.
(5)
Understands sophisticated materials, including those related to academic, medical and technical vocabulary.
Key for Writing Capability
30
Key
Writing
(1)
No functional ability to write the language and is only able to write single elementary words.
(2)
Able to write simple sentences. Requires major editing.
(3)
Writes on conventional and simple health care topics with few errors in spelling and structure.
Requires minor editing.
(4)
Writes on academic, technical, and most health care and medical topics with few errors in structure
and spelling.
(5)
Writes proficiently equivalent to that of an educated native speaker/writer. Writes with idiomatic ease
of expression and feeling for the style of language. Proficient in medical, healthcare, academic and
technical vocabulary.
Resources to Communicate Across Language Barriers
Primer on How Cultural Background
Impacts Health Care Delivery
Cultural Background—
Information on Special Topics
Use of Alternative or Herbal Medications
• People who have lived in poverty, or come from places
where medical treatment is difficult to get, will often
come to the doctor only after trying many traditional
or home treatments. Usually patients are very willing
to share what has been used if asked in an accepting,
nonjudgmental way. This information is important for the
accuracy of the clinical assessment.
• Many of these treatments are effective for treating the
symptoms of illnesses. However, some patients may not
be aware of the difference between treating symptoms
and treating the disease.
• Some treatments and “medicines” that are considered
“folk” medicine or “herbal” medications in the United
States are part of standard medical care in other countries.
Asking about the use of medicines that are “hard to find”
or that are purchased “at special stores” may get you a
more accurate understanding of what people are using
than asking about “alternative,” “traditional,” “folk,” or
“herbal” medicine.
Pregnancy and Breastfeeding
• Preferred and acceptable ages for a first pregnancy vary
from culture to culture. Latinos are more accepting of
teen pregnancy; in fact it is quite common in many of the
countries of origin. Russians tend to prefer to have children
when they are older. It is important to understand the
cultural context of any particular pregnancy. Determine
the level of social support for the pregnant woman, which
may not be a function of age.
• Acceptance of pregnancy outside of marriage also varies
from culture to culture and from family to family. In many
Asian cultures there is often a profound stigma associated
with pregnancy outside of marriage. However, it is important
to avoid making assumptions about how welcome any
pregnancy may be.
• Some Vietnamese and Latino women believe that colostrum
(a fluid in the breasts that nourishes the baby until the
32
breast milk becomes available) is not good for a baby.
An explanation from the doctor about why the milk
changes can be the best tool to counter any negative
traditional beliefs.
• The belief that breastfeeding works as a form of birth
control is very strongly held by many new immigrants. It
is important to explain to them that breastfeeding does
not work as well for birth control if the mother gets plenty
of good food, as they are more able to do here than in
other parts of the world.
Some treatments and “medicines” that are
considered “folk” medicine or “herbal”
medications in the United States are part of
standard medical care in other countries.
Weight
• In many poor countries, and among people who come
from them, “chubby” children are viewed as healthy children
because historically they have been better able to survive
childhood diseases. Remind parents that sanitary conditions
and medical treatment here protect children better than
extra weight.
• In many of the countries that immigrants come from,
weight is seen as a sign of wealth and prosperity. It has
the same cultural value as thinness has in our culture—
treat it as a cultural as well as a medical issue for better
success.
Infant Health
• It is very important to avoid making too many positive
comments about a baby’s general health.
- Among traditional Hmong, saying a baby is “pretty” or
“cute” may be seen as a threat because of fears that
spirits will be attracted to the child and take it away.
Resources to Increase Awareness of Cultural Background and Its Impact on Health Care Delivery
- Some traditional Latinos will avoid praise to avoid
attracting the “evil eye.”
- Some Vietnamese consider profuse praise as mockery.
• It is often better to focus on the quality of the mother’s
care—“the baby looks like you take care of him well.”
• Talking about a new baby is an excellent time to introduce
the idea that preventive medicine should be a regular
part of the new child’s experience. Well-baby visits may
be an entirely new concept to some new mothers from
other countries. Protective immunizations are often the
most accepted form of preventive medicine. It may be
helpful to explain well-baby visits and check-ups as a kind
of extension of the immunization process.
Substance Abuse
• When asking questions regarding issues of substance (or
physical) abuse, concerns about family honor and privacy
may come into play. For example, in Vietnamese and Chinese
cultures family loyalty, hierarchy, and filial piety are of the
utmost importance and may therefore have a direct effect
on how a patient responds to questioning, especially if
family members are in the same room. Separating family
members, even if there is some resistance to the idea, may
be the only way to accurately assess some of these problems.
• Women may have been raised with different standards
of personal control and autonomy than we expect in the
United States. They may be accepting physical abuse
not because of feelings of low self-esteem, but because
it is socially accepted among their peers, or because
they have nobody they can go to with their concerns. It
is important to treat these cases as social rather than
psychological problems.
• Immigrants learn quickly that abuse is reported and will
lead to intervention by police and social workers. Even
victims may not trust doctors, social workers, or police.
It may take time and repeated visits to win the trust of
patients. Remind patients that they do not have to answer
questions (silence may tell you more than misleading
answers). Using depersonalized conversational methods
will increase success in reaching reluctant patients.
• Families may have members with conflicting values and
rules for acceptable behavior that may result in conflicting reports about suspected physical abuse. This does
not necessarily mean that anyone is being deceptive, just
seeing things differently. This may cause special difficulties for teens who may have adopted new cultural values
common to Western society, but must live in families that
have different standards and behaviors.
• Gender roles are often expressed in the use or avoidance
of many substances, especially alcohol and cigarettes.
When discussing and treating these issues the social
component of the abuse needs to be considered in the
context of the patient’s culture.
• Behavioral indicators of abuse are different in different
cultures. Many people are not very emotionally and physically expressive of physical and mental pain. Learn about
the cultural norms of your patient populations to avoid
overlooking or misinterpreting unknown signs of trauma.
• Alcohol is considered part of the meal in many societies
and should be discussed together with eating and other
dietary issues.
• Do not confuse physical evidence of traditional treatments with physical abuse. Acceptable traditional
treatments, such as coin rubbing or cupping, may leave
marks on the skin, which look like physical abuse. Always
consider this possibility if you know the family uses traditional home remedies.
Physical Abuse
• Ideas about acceptable forms of discipline vary from culture
to culture. In particular, various forms of corporal punishment
are accepted in many places. Emphasis must be placed on
what is acceptable here, and what may cause physical harm.
Resources to Increase Awareness of Cultural Background and Its Impact on Health Care Delivery
33
Cultural Background—Information on Special Topics (continued)
Communicating with the Elderly
Gender roles
• Always address older patients using formal terms of
address unless you are directly told that you may use
personal names. Also remind staff that they should do
the same.
• Gender roles vary and change as the person ages (e.g.,
women may have much more freedom to openly discuss
sexual issues as they age).
• Stay aware of how the physical setting may be affecting
the patient. Background noise, glaring or reflecting light,
and small print forms are examples of things that may
interfere with communication. The patients may not say
anything, or even be aware that something physical is
interfering with their understanding.
• Stay aware that many people believe
that giving a patient a terminal
prognosis is unlucky or will bring
death sooner and families may not
want the patient to know exactly
what is expected to happen. If the
family has strong beliefs along these
lines the patient probably shares them.
Follow ethical and legal requirements,
but stay cognizant of the patient’s
cultural perspective. Offer the
opportunity to learn the truth, at
whatever level of detail desired by the patient.
• It is important to explain the specific needs for having
an advance directive before talking about the treatment
choices and instructions. This will help alleviate concerns
that an advance directive is for the benefit of the medical
staff rather than the patient.
• Elderly, low-literacy patients may be very skilled at disguising their lack of reading skills and may feel stigmatized by their inability to read. If you suspect this is the
case you should not draw attention to this issue but seek
out other methods of communication.
Talking About Sex
Consider the following strategies when navigating the
cultural issues surrounding the collection of sexual health
histories. Areas of cultural variation points to consider are:
34
• A patient may not be permitted to visit providers of the
opposite sex unaccompanied (e.g., a woman’s husband
or mother-in-law will accompany her to an appointment
with a male provider).
• Some cultures prohibit the use of sexual terms in front of
someone of the opposite sex or an older person.
• Several family members may accompany an older
patient to a medical appointment as a sign of respect
and family support.
• Before entering the exam room, tell the patient and their
companion exactly what the examination will include and
what needs to be discussed. Offer the option of calling
the companion(s) back into the exam room immediately
following the physical exam.
• As you invite the companion or guardian to leave the
exam room, have a health professional of the same gender
as the patient standing by and re-assure the companion
or guardian that the person will be in the room at all times.
• Use same sex non-family members as interpreters.
Sexual health and patient
cultural background
• If a sexual history is requested
during a non-related illness
appointment, patients may
conclude that the two issues—
for example, blood pressure and
sexual health are related.
• In many health belief systems
there are connections between
sexual performance and physical health that are different from the Western tradition. Example: Chinese males
may discuss sexual performance problems in terms of a
“weak liver.”
Resources to Increase Awareness of Cultural Background and Its Impact on Health Care Delivery
• Printed materials on topics of sexual health may be
considered inappropriate reading materials.
• Explain to the patient why you are requesting sexually
related information at that time.
• For young adults, clarify the need for collecting sexual
history information and consider explaining how you will
protect the confidentiality of their information.
• Offer sexual health education verbally. Whenever possible,
provide sexual health education by a health care
professional who is the same gender as the patient.
Confidentiality preferences
• Patients may not tell you about their preferences and
customs surrounding the discussion of sexual issues. You
must watch their body language for signals of discomfort,
or ask directly how they would like to proceed.
• A patient may be required to bring family members to
their appointment as companions or guardians. Printed
materials on topics of sexual health may be considered
inappropriate reading materials.
• Be attentive to a patient’s body language or comments
that may indicate that they are uncomfortable discussing
sexual health with a companion or guardian in the room.
• It may help to apologize for the need to ask sexual or
personal questions. Apologize and explain the necessity.
• Try to offer the patient a culturally acceptable way to
have a confidential conversation. Example: “To provide
complete care, I prefer one-on-one discussions with my
patients. However, if you prefer, you may speak with a
female/male nurse to complete the initial information.”
• Inform the patient and the accompanying companion(s)
of any applicable legal requirements regarding the
collection and protection of personal health information.
Pain Management Across Cultures
Your ability to provide adequate pain management to some
patients can be improved with a better understanding of
the differences in the way people deal with pain. Here is
some important information about the cultural variations
you may encounter when you treat patients for pain management. These tips are generalizations only. It is important
to remember that each patient should be treated as an
individual.
Do not mistake lack of verbal or facial expression
for lack of pain. Under-treatment of pain is
a problem in populations where stoicism is a
cultural norm.
Reaction to pain and expression of pain
• Cultures vary in what is considered acceptable expression
of pain. As a result, expression of pain will vary from stoic
to extremely expressive for the same level of pain.
• Some men may not verbalize or express pain because
they believe their masculinity will be questioned.
• Do not mistake lack of verbal or facial expression for
lack of pain. Under-treatment of pain is a problem in
populations where stoicism is a cultural norm.
• Because the expression of pain varies, ask the patient
what level, or how much, pain relief they think they need.
• Do not be judgmental about the way someone is expressing
their pain, even if it seems excessive or inappropriate to
you. The way a person in pain behaves is socially learned.
Spiritual and religious beliefs about using pain medication
• Members of several faiths will not take pain relief
medications on religious fast days, such as Yom Kippur
or daylight hours of Ramadan. For these patients,
religious observance may be more important than
pain relief.
• Other religious traditions forbid the use of narcotics.
Resources to Increase Awareness of Cultural Background and Its Impact on Health Care Delivery
35
Cultural Background—Information on Special Topics (continued)
• Spiritual or religious traditions may affect a patient’s
preference for the form of medication delivery, oral,
IV, or IM.
• Consultation with the family and Spiritual Counselor will
help you assess what is appropriate and acceptable.
Variation from standard treatment regimens may be
necessary to accommodate religious practices.
• Accommodating religious preferences, when possible,
will improve the effectiveness of the pain relief treatment.
• Offer a choice of medication delivery. If the choice is less
than optimal, ask why the patient has that preference and
negotiate treatment for best results.
Use of alternative pain relief treatment
• Your patient may be using traditional pain relief treatment,
such as herbal compresses or teas, massage, acupuncture
or breathing exercises.
• Respectfully inquire about all of the ways the patient is
treating his or her pain.
• Use indirect questions about community or family
traditions for pain management to provide hints about
what the patient may be using. There may be some
reluctance to tell you about alternative therapies until
they feel it is “safe” to talk about them.
• Accommodate or integrate your treatments with
alternative treatments when possible.
Methods needed to assess pain
• Most patients are able to describe their pain using a
progressive scale, but others are not comfortable using
a numerical scale, and the scale of facial expressions
(smile to grimace) may be more useful.
• Ask the patient specifically how they can best describe
their pain.
Beliefs about drug addiction
• Use multiple methods of assessing pain—scales and
analogies, if you feel the assessment of pain is producing
ambiguous or incorrect results.
• Recent research has shown that people from different
genetic backgrounds react to pain medication differently.
Family history and community tradition may contain evidence
about specific medication effects in the population.
• Once the severity of the pain can be assessed, explain in
detail the expected result of the use of the pain medication in
terms of whatever descriptive toolsthe patient has used.
Check comprehension with teach-back techniques.
• Past negative experience with pain medication shapes
current community beliefs, even if the medications and
doses have changed.
• Instead of using scales, which might not be known to the
patient, asking for comparative analogies, such as “like a
burn from a stove,” “cutting with a knife,” or “stepping on
a stone,” may produce a more accurate description.
• Be aware of potential differences in the way medication
acts in different populations. A patient’s belief that he or
she is more easily addicted may have a basis in fact.
• Explain how the determination of type and amount of
medication is made. Explain changes from past practices.
Accommodate or integrate your treatments with
alternative treatments when possible.
• Assure your patient you are watching his or her particular case.
36
Resources to Increase Awareness of Cultural Background and Its Impact on Health Care Delivery
Regulations and Standards for Cultural
and Linguistic Services
Standards to Provide Culturally and
Linguistically Appropriate Services
(CLAS)
Below is an informal summary of excerpts from the Office
of Minority Health’s publication entitled “Assuring Cultural
Competence in Health Care: Recommendations for National
Standards and an Outcomes-Focused Research Agenda.”
1. Patients/consumers must receive from all staff: effective,
understandable, and respectful care that is provided in
a manner compatible with their cultural health beliefs
and practices of preferred language.
9. Organizational self-assessments must be conducted
regarding CLAS-related activities, and cultural and
linguistic competence measures should be incorporated into internal audits, performance improvement
programs, patient satisfaction assessments, and
outcome-based valuations.
2. Strategies should be implemented to recruit, retain,
and promote a diverse staff and organizational leadership that are representative of the demographic
characteristics of the service area.
10. Data on race, ethnicity, and language difference should
be collected in patient/consumer health records,
integrated into the information management systems
and updated periodically.
3. Staff at all levels and across all disciplines should
receive ongoing education and training in culturally
and linguistically appropriate service delivery.
11. Current demographic, cultural, and epidemiological
profiles of the communities served should be maintained,
as well as needs assessments to accurately plan for
and implement services that respond to the cultural
and linguistic characteristics of the service area.
4. Language assistance services must be offered and
provided, including bilingual staff and interpreter
services, at no cost to each patient/consumer with
limited English proficiency at all points of contact, in a
timely manner, during all hours of operation.
5. Patients/consumers must be provided verbal and written
notices about their right to receive language assistance
services; these notices must be in their language
of preference.
6. Language assistance provided to Limited English
Proficient (known as “LEP”) patients must be provided
by competent interpreters and bilingual staff. Family and
friends should not be used for interpretation services.
7. Easily understood patient-related materials and signage
must be made available/posted in languages of the
commonly encountered groups represented in the
service area.
8. A written strategic plan should be developed, implemented and promoted, outlining clear goals, policies,
38
operational plans, and management accountability/
oversight mechanisms to provide culturally and
linguistically appropriate services.
Regulations and Standards for Cultural and Linguistic Services
12. Participatory and collaborative relationships with
communities should be established and a variety of
formal and informal mechanisms should be used to
facilitate community and patient/consumer involvement
in designing and implementing CLAS-related activities.
13. Conflict and grievance resolution processes must be
culturally and linguistically sensitive, and capable of
identifying, preventing and resolving cross-cultural
conflicts or complaints by patients/consumers.
14. Information should be made public regularly regarding
progress and successful innovations in implementing
CLAS standards, and inform the public and the impacted
communities about the availability of such information.
Title VI of the Civil Rights Act of 1964
“No person in the United States shall, on the ground of race, color or national origin, be
excluded from participation in, be denied the benefits of, or be subjected to discrimination
under any program or activity receiving federal financial assistance.”
Under Title VI, any agency, program, or activity that receives
funding from the federal government may not discriminate
on the basis of race, color or national origin. This is the oldest
and most basic of the many federal and state laws requiring
“meaningful access” to healthcare, and “equal care” for
all patients. Other federal and state legislation protecting
the right to “equal care” outline how this principle will be
operationalized.
State and Federal courts have been interpreting Title VI,
and the legislation that it generated, ever since 1964. The
nature and degree of enforcement of the equal access
laws has varied from place to place and from time to time.
Recently, however, both the Office of Civil Rights and the
Office of Minority Health have become more active in
interpreting and enforcing Title VI.
Additionally, in August 2000, the U.S. Department of
Health and Human Services Office of Civil Rights issued
“Policy Guidance on the Prohibition Against National Origin
Discrimination As it Affects Persons with Limited English
Proficiency.” This policy established “national origin” as
applying to limited English-speaking recipients of federally
funded programs.
Regulations and Standards for Cultural and Linguistic Services
39
Executive Order 13166, August 2000, Improving Access
to Services for Persons With Limited English Proficiency
(Verbatim)
By the authority vested in me as President by the Constitution and the laws of the United States of America, and to
improve access to federally conducted and federally assisted programs and activities for persons who, as a result
of national origin, are limited in their English proficiency
(LEP), it is hereby ordered as follows:
sets forth the compliance standards that recipients must
follow to ensure that the programs and activities they normally provide in English are accessible to LEP persons and
thus do not discriminate on the basis of national origin in
violation of title VI of the Civil Rights Act of 1964, as amended, and its implementing regulations. As described in the
LEP Guidance, recipients must take reasonable steps to
ensure meaningful access to their programs and activities
by LEP persons.
Sec. 2. Federally Conducted Programs
and Activities.
Section 1. Goals.
The Federal Government provides and funds an array of
services that can be made accessible to otherwise eligible
persons who are not proficient in the English language. The
Federal Government is committed to improving the accessibility of these services to eligible LEP persons, a goal that
reinforces its equally important commitment to promoting
programs and activities designed to help individuals learn
English. To this end, each Federal agency shall examine the
services it provides and develop and implement a system by
which LEP persons can meaningfully access those services
consistent with, and without unduly burdening, the fundamental mission of the agency. Each Federal agency shall
also work to ensure that recipients of Federal financial
assistance (recipients) provide meaningful access to their
LEP applicants and beneficiaries. To assist the agencies
with this endeavor, the Department of Justice has today
issued a general guidance document (LEP Guidance), which
40
Regulations and Standards for Cultural and Linguistic Services
Each Federal agency shall prepare a plan to improve access
to its federally conducted programs and activities by
eligible LEP persons. Each plan shall be consistent with the
standards set forth in the LEP Guidance, and shall include
the steps the agency will take to ensure that eligible LEP
persons can meaningfully access the agency’s programs
and activities. Agencies shall develop and begin to implement these plans within 120 days of the date of this order,
and shall send copies of their plans to the Department of
Justice, which shall serve as the central repository of the
agencies’ plans.
Sec. 3. Federally Assisted Programs and Activities.
Each agency providing Federal financial assistance shall
draft title VI guidance specifically tailored to its recipients that is consistent with the LEP Guidance issued by
the Department of Justice. This agency-specific guidance
shall detail how the general standards established in the
LEP Guidance will be applied to the agency’s recipients.
The agency-specific guidance shall take into account the
types of services provided by the recipients, the individuals served by the recipients, and other factors set out in
the LEP Guidance. Agencies that already have developed
title VI guidance that the Department of Justice determines
is consistent with the LEP Guidance shall examine their
existing guidance, as well as their programs and activities,
to determine if additional guidance is necessary to comply
with this order. The Department of Justice shall consult
with the agencies in creating their guidance and, within 120
days of the date of this order, each agency shall submit its
specific guidance to the Department of Justice for review
and approval. Following approval by the Department of
Justice, each agency shall publish its guidance document in
the Federal Register for public comment.
Sec. 4. Consultations.
In carrying out this order, agencies shall ensure that
stakeholders, such as LEP persons and their representative
organizations, recipients, and other appropriate individuals or entities, have an adequate opportunity to provide
input. Agencies will evaluate the particular needs of the LEP
persons they and their recipients serve and the burdens
of compliance on the agency and its recipients. This input
from stakeholders will assist the agencies in developing an
approach to ensuring meaningful access by LEP persons
that is practical and effective, fiscally responsible, responsive to the particular circumstances of each agency, and
can be readily implemented.
Sec. 5. Judicial Review.
This order is intended only to improve the internal management of the executive branch and does not create any right
or benefit, substantive or procedural, enforceable at law or
equity by a party against the United States, its agencies, its
officers or employees, or any person.
WILLIAM J. CLINTON
THE WHITE HOUSE
Office of the Press Secretary
(Aboard Air Force One)
_________________________________________________
For Immediate Release August 11, 2000
Reference: http://www.usdoj.gov/crt/cor/Pubs/eolep.htm
Regulations and Standards for Cultural and Linguistic Services
41
Resources for Cultural and Linguistic Services
Cultural Competence Website Links to Other Organizations
General Cultural Competence
Resources for Cross-Cultural Health Care
http://www.diversityrx.org
DHHS Health Resources and
Services Administration
http://www.hrsa.gov/healthliteracy/
Culture, Health and Literacy: A Guide to Health
Education for Adults with Limited Literacy Skills
http://healthliteracy.worlded.org/docs/culture/
National Academies Press
http://books.nap.edu/books/0309071542/html/index.html
National Center For Cultural Competence,
Georgetown University
http://www11.georgetown.edu/research/gucchd/nccc/
National Council on Interpreting in Health Care
http://www.ncihc.org
Department of Justice – Office of Civil Rights
http://www.justice.gov/crt/about/cor/13166.php
The State of Literacy in America
http://nces.ed.gov/naal/estimates/
Office of Minority Health
http://minorityhealth.hhs.gov/
Office of Minority Health – “A Physician’s Practical
Guide to Culturally Competent Care”
https://cccm.thinkculturalhealth.hhs.gov/
DHHS Office of Civil Rights
http://www.hhs.gov/ocr/
The Cross Cultural Health Care Program
http://www.xculture.org/
The Plain Language Association International
http://www.plainlanguagenetwork.org/
Kaiser Family Foundation Minority Health
http://www.kff.org/minorityhealth/index.cfm
Yale University Cultural Competence Resources
http://www.med.yale.edu/library/education/culturalcomp
Agency for Healthcare Research and Policy:
“Providing Care To Diverse Populations”
http://www.ahcpr.gov/news/ulp/ulpcultr.htm
AMSA Diversity in Medicine
http://www.amsa.org/AMSA/Homepage/About/Priorities/
Diversity.aspx
Resources for Cultural and Linguistic Services
43
Cultural Competence Website Links to Other Organizations (continued)
General Cultural Competence (continued)
Institute of Medicine: Unequal Treatment
http://www.iom.edu/Reports/2002/Unequal-TreatmentConfronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx
Robert Woods Johnson Foundation:
Aligning Forces for Quality
http://www.rwjf.org/newsroom/product.jsp?id=30951
Wall Street Journal, June 5, 2008: Health Care
Has Racial, State Disparities
http://online.wsj.com/article/SB121263635211447647.html?
mod=dist_smartbrief
AskMe3 Brochures - Partnership for
Clear Health Communication
http://www.npsf.org/for-healthcare-professionals/
programs/ask-me-3/
Aging
Center on an Aging Society
http://ihcrp.georgetown.edu/agingsociety/
AARP Aging and Minorities
http://www.aarp.org/politics-society/rights/info-1995/a_portrait_
of_older_minorities.html
African American
44
National Association of Black Cardiologists
http://www.abcardio.org/
National Black Nurses Association
http://www.nbna.org/
Resources for Cultural and Linguistic Services
American Indian/Alaskan Native
Association of American Indian Physicians
http://www.aaip.org/
Native American Cancer Research
http://natamcancer.org/
National Indian Council on Aging
http://www.nicoa.org
National Indian Health Board
http://www.nihb.org/
National Resource Center on Native
American Aging
http://ruralhealth.und.edu/projects/nrcnaa/
Asian American/Pacific Islander American
Asian & Pacific Islander American Health Forum
http://www.apiahf.org/
Chinese American Medical Society
http://www.camsociety.org/
Office on Women's Health
http://www.womenshealth.gov/minority-health/asian-americans/
National Asian Pacific Center on Aging
http://www.napca.org/
Resources for Cultural and Linguistic Services
45
Cultural Competence Website Links to Other Organizations (continued)
Hispanic/Latino American
National Alliance for Hispanic Health
http://www.hispanichealth.org/
National Council of La Raza
http://www.nclr.org
National Hispanic Council on Aging
http://www.nhcoa.org
National Hispanic Medical Association
http://www.nhmamd.org
Free Patient Health Education Materials – Low Literacy and Other Languages
National Institutes of Health –
Health Information in English/Spanish
http://www.health.nih.gov
National Network of Libraries of Medicine –
Easy to Read Health Brochures in Other Languages
http://nnlm.gov/outreach/consumer/multi.html
Remember, web pages can expire often. If the web address provided does not work, use a search engine and search under the
organization’s name.
This information is intended for educational purposes only, and should not be interpreted as medical advice. Please consult
your doctor for advice about changes that may affect your health.
Linkage to the websites listed is for educational purposes only and is not intended as a particular endorsement of any organization.
46
Resources for Cultural and Linguistic Services
Our Health Plan’s Cultural
and Linguistic Resources
Visit our new website at BridgingHealthCareGaps.com!
If you have any questions or comments about this toolkit, please contact your provider representative.
Sources Used in the Production of This Toolkit
Bibliography of Major Hard-Copy Sources
Used in the Production of the ICE Toolkit
Aguirre-Molina, M., et al. Health Issues in the Latino Community. San Francisco: Jossey-Bass. 2001
Avery, C. “Native American Medicine: Traditional Healing.” JAMA 265 (1991): 2271-2273.
Baer, H. Biomedicine and Alternative Healing Systems in America. Madison, WI: University of Wisconsin Press. 2001
Bonder, B., Martin, L., & Miracle, A. (n.d.). Culture in Clinical Care. Thorofare, NJ: SLACK, Inc.
Carillo, J.A., Green., & J. Betancourt. “Cross–Cultural Primary Care: A patient-based approach.” Annals of Internal Medicine 130, (1999): 829-834.
California Healthcare Interpreters Association & CHIA Standards and Certification Committee (Eds.). California Standards for Healthcare Interpreters:
Ethical Principal, Protocols, and Guidance on Roles and Interventions. Oxnard, CA: The California Endowment.
Cross, T., Dennis, KW., et al. Towards a Culturally Competent System of Care. Washington, DC: Georgetown University. 1989
Doak, C., et al. Teaching Patients with Low Literacy Skills. Philadelphia: J.B. Lippincott Co. 1996
Duran, D., et al. (Eds.). A Primer for Cultural Proficiency: Towards Quality Health Services for Hispanics. Washington D.C.: National Alliance
for Hispanic Health. 2001
Fadiman, A. The Spirit Catches You and You Fall Down. New York: Farrar, Strauss & Giroux. 1997
Galanti, G. Caring for Patients from Different Cultures. Pennsylvania, PA: University of Pennsylvania Press. 1997
Goodman, A., et al. Nutritional Anthropology: Biocultural Perspectives on Food and Nutrition. Mountainview, CA: Mayfield Publishing Company. 2000
Hall, E.T. Hidden Differences: Studies in International Communication. Hamburg, Germany: Gruner & Jahr. 1985
Hall, E.T. Understanding Cultural Differences. Yarmouth, ME: Intercultural Press. 1990
Harwood, A. (Eds.). Ethnicity and Medical Care. Cambridge, MA: Harvard University Press. 1981
Kaiser Permanente National Diversity Council. (1999). Provider’s Handbook on Culturally Competent Care. Oakland, CA: Kaiser Permanente.
Kleinman, A. Patients and Healers in the Context of Culture. Berkeley, CA: University of California Press. 1980
Kleinman, A. Illness Narratives. New York: Perseus Publishing. 1990
Kleinman, A., & Good, B. (Eds.). Culture and Depression. Berkeley, CA: University of California Press. 1985
Leslie, C., & Young, A. (Eds.). Paths to Asian Medical Knowledge. Berkeley, CA: University of California Press. 1992
Leigh, JW. Communicating for Cultural Competence. New York: Allyn and Bacon. 1998
Lipson, J., Dibble, S., et al. (Eds.). Culture and Nursing Care: A Pocket Guide. San Francisco: UCSF Nursing Press. 1996
O’Conner, B. Healing Traditions: Alternative Medicine and the Health Professions. Philadelphia: University of Pennsylvania Press. 1995
Office of Minority Health, Department of Health and Human Services. “Assuring cultural competence in health care: Recommendations for national standards
and an outcomes-focused research agenda.” Federal Register Volume 65, 247. (2000): 80865-80879.
Office of Minority Health, Department of Health and Human Services. National standards for culturally and linguistically appropriate services in
health care: Final Report. 2001
Purnell, L.D., & Paulanka, B.J. Transcultural Health Care: A Culturally Competent Approach. Philadelphia, PA: F.A. Davis Company. 1998
Salimbene, S. What Language Does Your Patient Hurt In? A Practical Guide to Culturally Competent Care. Northampton, MA: Inter-Face International, Inc. 2000
Smedley, B., Stith, A., & Nelson, A. (Eds.). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC:
National Academy Press. 2002
Spector, R. Cultural Diversity in Health and Illness: a Guide to Heritage Assessment and Health Traditions. Boston: Appleton & Lange. 1996
Spector, R. Cultural Diversity in Health and Illness. Upper Saddle, NJ: Prentice Hall Health. 2000
U.S. Code. “Title VI of the Civil Rights Act of 1964.” Title 42 - The Public Health and Welfare. 42 U.S.C. § 2000d et seq. 1964
Walzer, J. “The Health of Hispanic Elders: The Intersection of Nutrition Culture and Diabetes.” Tufts Nutrition. 2 May 2002
Please refer to the “Web Resources” pages of this toolkit to find the Internet resources that informed the work of the ICE Committee.
Sources Used in the Production of This Toolkit
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Bibliography of Major Internet Sources
Used in the Production of the ICE Toolkit
“A Practical Guide for Implementing the Recommended National Standards for Culturally and Linguistically Appropriate Services in Health Care.”
Office of Minority Health. December 2001 <http://minorityhealth.hhs.gov/assets/pdf/checked/CLAS_a2z.pdf>
“Culturally Competent Organizations. CLAS Standards.” Management Sciences for Health. 2003
<http://erc.msh.org/mainpage.cfm?file=9.4.htm&module=provider&language=Englis>
“Culturally and Linguistically Appropriate Standards of Care.” As approved by the Boston HIV Health Services Planning Council on
11 January 2001 <http://www.bphc.org>
“Healthy People 2010.” Blue Cross and Blue Shield of Florida. 2002 <http:// www.bcbsfl.com>
“Information and Guidance for Recipients of Federal Funds on Language Access to Federally Assisted Programs and Activities.”
Department of Justice, Civil Rights Division, Executive Order 13166. 2003 <http://www.lep.gov>
Office of the Press Secretary, The White House. "Improving Access to Services for Persons with Limited English Proficiency. (Verbatim)."
Department of Justice, Civil Rights Division, Executive Order 13166. 11 August 2000 <http://www.usdoj.gov/crt/cor/Pubs/eolep.htm>
“Operational Policy Letter #: OPL 2001.133.” Department of Health and Human Services Centers for Medicare & Medicaid Services.
16 July 2001 <http://web.archive.org/web/20050308051355/http://www.cms.hhs.gov/healthplans/opl/opl133.pdf>
“Oral, Linguistic, and Culturally Competent Services: Guides for Managed Care Plans.” Agency for Healthcare Research and Quality.
Rockville, MD. 2003 <http://www.ahrq.gov/populations/cultcomp.htm>
“The Medicare Advantage Organization National QAPI Project for 2003.” Centers for Medicare and Medicaid Services. 2004
<http://www.ahrq.gov/populations/oralling.htm>
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Sources Used in the Production of This Toolkit